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Full text of "United States Navy Medical News Letter Vol. 34 No. 11, 4 December 1959"

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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Donald R. Chllds MC USN - Editor 



Vol. 34 



Friday, 4 December 1959 



No. 11 



TABLE OF CONTENTS 



Historical Fund of the Navy Medical Department , 

ABSTRACTS • DENTAL SECTION 



Immediate Therapy in Burns 3 

Surgery for Hypertension Due 

to Occlusive Renal Disease 6 

Calcaneal Stress Fractures 7 

Bell's Palsy 9 

Transfusion of Cadaver Blood 10 

Endocrine s and Peptic Ulcer 12 

Making Sense 13 

MISCELLANEOUS 

Association of Military Surgeons 
Elects Officers and Presents 

Awards 16 

American Board Exams (Obstetrics 

and Gynecology) 17 

Public Health Training 18 

Military Pediatrics 18 

From the Note Book 19 



U. S. - New Zealand Study 22 

TV Optical System 22 

Leadership , 24 

Special Lecture at Dental School 25 

Reserve Seminar for CO's 26 

Forwarding of Orders ■ . 26 

RESERVE SECTION 

Dermatology Round Table 2 7 

Publications for Reservists .... 27 

Reserve Terminology 28 

PREVENTIVE MEDICINE 

Respiratory Disease in Industry 29 

Tetanus Immunization 31 

Hospital Sanitation 33 

Driving Hazards After Sundown 3 7 

Standard Laboratory Methods ... 38 



SPECIAL NOTICE 39 



Medical News Letter, Vol. 34, No. 11 



HISTORICAL FUND 

of the 

NAVY MEDICAL DEPARTMENT 



A committee has been formed with representation from the Medical 
Corps, Dental Corps, Medical Service Corps, Nurse Corps, and 
Hospital Corps for the purpose of creating a fund to be used for the 
collection andmaintenance of items of historical interest to the Medical 
Department. Such items will include, but will not be limited to, por- 
traits, memorials, etc. , designed to perpetuate the memory of dis- 
tinguished mennbers of the Navy Medical Departnaent. These memorials 
will be displayed in the Bureau of Medicine and Surgery and at the 
National Naval Medical Center. Medical Departnrxent officers, active 
and inactive, are invited to make small contributions to the fund. It is 
emphasized that all donations must be on a strictly voluntary basis . 
Funds received will be deposited in a Washington, D. C. bank to the 
credit of the Navy Medical Department Historical Fund, and will be 
expended only as approved by the Committee or its successor and for 
the objectives stated. 

It is anticipated that an historical committee will be organized at each 
of our medical activities. If you desire to contribute, please do so 
through your local historical committee or send your check direct, 
payable to Navy Medical Department Historical Fund, and mail to: 

Treasurer, N. M.D. Historical Fund 
Bureau of Medicine and Surgery (Code 14) 
Departnnent of the Navy 
Washington 25, D. C. 



Committee 

F. P. GILMORE, Rear Admiral (MC) USN, Chairman 
C. W. SCHANTZ, Rear Admiral (DC) USN 
L. J. ELSASSER, Captain (MSC) USN 
R. A. HOUGHTON, Captain (NC) USN 
T. J. HICKEY, Secretary-Treasurer 



Medical News Letter, Vol. 34, No. 11 



Immediate Therapy in Burns 

The first step in management of burn injury is rapid determination of 
the magnitude of the burn. This is dependent on the percentage of total body 
surface injured and depth of the burn wound. The burned area may be esti- 
mated by applying the "Rule of Nines, " which is familiar to all. Although 
this rule is not exact, it is sufficiently accurate to serve as the basis for 
estimating initial replacement therapy required in a burned patient. 

Depth of the burn injury is of significance because third-degree burns 
destroy or trap more red blood cells and cause greater physiologic derange- 
ment than do second-degree burns. Consequently, third-degree burns not 
only require skin grafting for healing, but may be considered twice as serious 
as second-degree burns in a prognostic sense, A 25% third-degree total body 
burn is equivalent to about a 50% second-degree total body burn. 

Mechanical or radiation injury concomitant with thermal trauma de- 
creases the possibility of survival. Patients sustaining danaage to the upper 
respiratory tract frequently develop hypoxia and are more susceptible to pul- 
monary edema. Tolerance of thermal injury is decreased in elderly individ- 
uals, infants, and persons with pre-existing disease. 

Treatment of burn injuries may be conveniently divided into several 
phases, each of which is described separately. 

Sedation . All burned patients have pain to some degree, and hysteria 
is common. Morphine, given intravenously in small doses, is the drug of 
choice for effective management of pain and anxiety. Because oxygenation 
often controls restlessness and apprehension, oxygen administration is a 
definite therapeutic tool in the early postburn phase. ■ . 

Intravenous pathway . A constant finding in thermal injury is edema 
beneath the involved area and exudation of fluid from the burned surfaces. 
In addition, destruction and trapping of red blood celts occur. To enable 
adequate fluid replacement, usually for a prolonged period of time, intro- 
duction of a polyethylene catheter is superior to repeated venipuncture. 

Urinary Drainage . Often it is impossible to make blood pressure readings 
on burned patients, and other clinical signs of shock frequently cannot be 
elicited. Experience has demonstrated that the best single indication of 
adequate replacement therapy is an adequate output of urine. Therefore, a 
retention urinary catheter may allow measurement of output at frequent 
intervals. 

Fluid and Electrolyte Replacement . The Brooke formtila for resusci- 
tative therapy is used by the author to estimate the requirement for initial 
replacement of fluids. Each patient must be treated individually, with the 
formula serving only as a guide. During the first 24 hours after injury, the 
Brooke formula recommends this administration of replacement solutions 
for adults: 



Medical News Letter, Vol. 34, No. 11 



1. Colloids {blood, dextran, plasma) — 0.5 ml. x kg. weight x % body- 
surface burn 

Z. Electrolytes (lactated Ringer's or isotonic saline solution) — 1.5 ml. x 
kg. weight X % body surface burn 

3. Dextrose in water (5 or 10% solution) — Z, 000 ml. 

Only areas of second and third degree burn are considered in determin- 
ing the requirement for replacement fluids. If the total area of burn involves 
more than 50% of the body surface, therapy is calculated on the basis of a 50% 
surface area burn. 

During the second Z4 hours after injury, colloid and electrolyte require- 
ments are approximately one-half of the amount estimated for the first 24 hours. 
However, replacement of insensible fluid loss renaains the sarae as in the first 
24 hours — 2, 000 ml. or more of 5% dextrose in water. 

Whole blood is seldom required in treatment of second-degree burns in- 
volving less than Z5% total body surface. The amount of whole blood in the 
estimated replacement of colloids is directly proportional to the depth and 
extent of the burn injury. The author gives about one-half of the colloid re- 
quirement as whole blood in burns of 30%, and about three -fourths of the cal- 
culated colloid replacement requirement as whole blood in burns of 50% of the 
body surface. 

One -half of the estimated amount of each of the replacement solutions 
for the first day is administered during the first 8 hours; the remainder in 
equal amounts during the next two 8 -hour periods. If replacement therapy is 
adequate, an adult will have a urinary output of 30 to 50 nnl, per hour. Any 
output of less or more volume demands careful adjustment of volume of fluid 
being administered. 

Because paralytic ileus may occur during the first Z4 to 48 hours, oral 
fluids and food usually are witheld. When fluids can be given, the fluid should 
consist of a hypotonic electrolyte solution — 3 gm. sodiuna chloride and 1. 5 gm. 
sodium bicarbonate in 1,000 ml. water. In adequately and vigorously treated 
patients, spontaneous diuresis will begin between the third and fifth postburn 
day. At this time, the serum sodium tends to become elevated because of 
mobilization from edema under the burned areas. Therefore, after the second 
postburn day, 5% dextrose in water to maintain hydration is given, and the 
serum sodium concentration is maintained at about 135 nnEq/liter. Potassium 
chloride, 60-lZO mEq. , orally or parenterally also is administered. Trans- 
fusions of whole blood are given as required to maintain the hematocrit at 
approximately 45%. 

Adequate and early replacement of fluids will prevent oliguria and renal 
failure. After 48 hours, a high-protein, high-caloric, and high-vitamin diet — 
liquid or solid— is urged as tolerated. 

Tracheostonn.y . This procedure may be life saving when indicated and 
facilitates administration of anesthesia to those with burns about the face. 



Medical News Letter, Vol. 34, No. 11 



Antibiotics . Prophylactic penicillin, streptomycin, or broad spectrum 
antibiotics are indicated for control of streptococcal infection, commonly 
occurring during the first 3 to 5 days. Subsequently, bacterial cultures and 
sensitivity tests indicate which antibiotics are required. Routine antibiotic 
therapy is not necessary for minor burns of 20% or less of the body surface. 

Tetanus Prophylaxis . Patients who have not been actively immunized 
should be given an injection of at least 3,000 units of tetanus antitoxin unless 
exhibiting sensitivity, and those having been immunized require only a booster 
dose of toxoid. 

Local Therapy. When an adequate hourly output of urine is obtained and 
the patient has responded to resuscitative therapy, he is taken to the operating 
room. Under analgesia or anesthesia, the entire area is gently but thoroughly 
washed with a surgical soap or detergent containing hex^chloraphene followed 
by copious rinses with normal saline. The wound is then debrided of all foreign 
matter and loose epithelial tissues. 

At this time, decision must be made as to type of local therapy to be used. 
As a general statement, the author prefers the exposure method when feasible, 
inasmuch as his experience has shown that patients do better with this type of 
management than with occlusive dressings. Small areas of third-degree burns 
are occasionally excised and grafted. Other burns receive therapy as indicated 
by various factors. 

When occlusive dressings are employed, they consist of a single layer 
of fine -mesh petrolatum gauze laid circumferentially in strips over the burn 
wound, bulky gauze fluffs or mechanics waste placed next, with large padded 
dressing similar to abdominal pads fornaing the outer layer, A semi-stretch- 
able gauze is applied to maintain these dressings in position and to give very 
light, even pressure and immobilization. These dressings must be changed 
every 3 or 4 days. 

When the open method is employed and the eschar cracks, the wound may 
be treated by wet soaks, surgical debridement, and occlusive dressings in order 
to remove the eschar and prepare the granulating tissues for grafting. 
(LTCOL E, H. Vogel Jr. , MC USA, Brooke Army Medical Center, Immediate 
Therapy in Burns: GP, XX: 121-124, October 1959) 

NOTE: Schilling, et al. , in the October Annals of Surgery, describe a new 
approach to fluid therapy of the severely burned patient, employing urea as 
an electrolyte substitute. The prompt diffusibility of urea into all tissue 
fluid compartments and its prompt excretion as an obligatory diuretic make 
it seemingly an ideal solution to administer as a substitute for a major por- 
tion of the sodium and electrolyte that is ordinarily given to severely burned 
patients. It is of interest that each of the patients in this report excreted 
about three times the volume of urine they might have been expected to ex- 
crete under the Brooke Arnny Hospital regimens and received about one- 
third as much sodium. The kidneys were protected from the hazards of 



Medical News Letter, Vol. 34, No. 11 



hypovolemia, oliguria, or anuria. In other clinical regards, the patients 
seemed to fare better than with other regimens. Results in these patients 
warrant further use and evaluation of this form of therapy. 

Cognizant of significant depletion of nitrogen stores from the body in 
instances of severe burns, Kroulik, reporting in The Journal of the Inter- 
national College of Surgeons for October 1959, employed norethandrolone 
(Nilevar) to offset this catabolic reaction. Treatment of 33 victinn.s of the 
fire at Our Lady of the Angels School in Chicago, with and without this ster- 
oid, indicated that there was promotion of wound healing and improved main- 
tenance of general metabolic status. 



Surgery for Hypertension Due to 
Occlusive Disease of Renal Arteries 

The most connnnon cause of remediable renal hypertension is occlusive 
disease of the renal artery or its major branches. The use of translumbar 
aortography to demonstrate the arterial supply of the kidneys in hypertensive 
patients has led to the clinical recognition of these previously unsuspected 
arterial causes of renal hypertension. 

Since January 1955, aortography has been used extensively in hyper- 
tensive patients at the Cleveland Clinic, and through March 1959. 33 7 hyper- 
tensive patients were examined by renal angiography. Occlusive disease of 
one or both renal arteries was found in 87 patients, with the occlusive lesion 
being considered the primary cause of hypertension in the majority of these 
patients, but in some the lesion was thought to be a complication of existing 
essential hypertension. 

After evaluation of various factors, indications for renal angiography 
in hypertension are considered to be: (1) disparity in length or excretory 
function of the kidneys as revealed by intravenous urography; (2) hyperten- 
sion in a patient less than 35 years of age in whom no other cause for hyper- 
tension can be found; (3) malignant hypertensive syndrome that develops in a 
patient more than 55 years of age; (4) nonfamilial hypertension of recent 
onset and (5) hypertension that develops or worsens after an episode of flank 
or abdominal pain. 

The majority of the renal arterial occlusive lesions were arteriosclerotic 
plaques, with or without superimposed thrombosis, but in about one -fifth of 
the patients from whom surgical specimens were obtained the stenosis was due 
to fibromuscular subintimal proliferation. Thrombosis of the renal artery with- 
out other pathologic findings in the artery was present in 5 patients. Small 
dissecting aneurysms of the renal artery or one of its major branches were 
found in 3 patients. These arterial lesions caused variable effects on the renal 
parenchyma ranging from no abnormality in a few patients to tubular atrophy, 



Medical News Letter, Vol. 34, No. 11 



minimal to severe, focal to diffuse, in others. Complete occlusion of a branch 
of the renal artery resulted in ischemic atrophy of the corresponding vascular 
segment of the kidney. 

Surgical treatment of renal arterial lesions associated with hypertension 
should: (1) relieve hypertension and hypertensive vascular disease promptly 
and permanently, and (2) when possible, restore normal renal function to the 
affected kidney. Of the 93 patients reported, 66 were selected for surgical 
treatment. Thirty-nine patients had nephrectomy, and 30 had some other type 
of surgical procedure designed to preserve the affected kidney. More than one 
operation was necessary in several patients. Other than nephrectonay, proced- 
ures included: segmental nephrectomy, endarterectomy, excision of occluded 
segment of renal artery, renal arterial homografts, and splenorenal arterial 
anastomosis. 

Of the hypertensive patients with occlusive disease of the renal arteries 
who had surgical treatment and are living, about 80% now have normal blood 
pressure, or have residual systolic hypertension with normal diastolic pres- 
sure. The latter situation is compatible with widespread atherosclerosis and 
inelasticity of the large arteries. Restoration of excretory function of a kidney 
with previously occluded main artery has been documented in a number of 
patients, employing glomerular filtration rate, volume of urine in ml. /min. , 
urinary osmolarity, and urinary sodium concentration. (Poutasse, E. F. , 
Surgical Treatment of Renal Hypertension; Results in Patients with Occlusive 
Lesions of Renal Arteries: J. Urol., 82:403-411, October 1959) 

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Stress Fractures of the Calcaneus 

Stress, march, fatigue, or insufficiency fracture can be defined as a 
break in the continuity of presumably normal bone caused by rhythmically 
recurring subthreshold traumata. Bone exhaustion, analogous to the fatigue 
of common metals, is the theory held by most observers today as being the 
mechanism of the fracture. 

In the present study, 134 patients with stress fractures of the calcaneus 
were diagnosed in U.S. Marine Corps recruits at Parris Island, S. C. , from 
January 1957 to August 1958, The incidence was 0. 45% of the total number 
of new recruits. In this study, 98 patients had bilateral fractures, 17 of the 
right heel alone, and 19 of the left heel alone. Thirteen of the total number 
had a history of having been physically active or having participated in athletic 
endeavor in the 3 years prior to enlistment. Fifty-eight were over 20 years of 
age, the oldest was 26, and the average was 20. The percentage of concur- 
rence of abnormal foot structure was not significant. Comparison of age and 
physical activity of the patients with calcaneal fractures with that of all re- 
cruits revealed that patients with fractures were older and had been less active 
prior to enlistnient. 



8 Medical News Letter, Vol. 34, No. 11 



All patients complained of painful swelling of the heel which occurred 
during the first 10 days of training. No history of specific trauma could be 
elicited. However, most patients considered that "digging in" — forceful 
stamping with heel during marching — was responsible, and it was known that 
during the first 2 weeks of training the recruit must walk "double time" every- 
where and is on his feet for 8 to 10 hours a day. 

Two signs could always be elicited — edema in the area of the precalcan- 
eal bursa and tenderness over the posterosuperior calcaneus. Roentgenogranns 
were negative at the time of the first examination which was normally 3 to 5 
days after the onset of symptoms. Ten days after onset of symptoms a definite 
line or density usually could be seen in the posterosuperior portion of the cal- 
caneus. The earliest time at which a fracture was visualized was 7 days after 
onjet of symptoms; the latest was 30 days. 

Treatment consisted of bed rest for one week, after which four -point 
weight-bearing crutches were instituted with one-half inch sponge-rubber 
heel inserts in both shoes. Crutches were discontinued when symptoms per- 
mitted — usually in 4 to 6 days — at which tinae those patients with negative 
roentgenograms were returned to duty if symptoms did not recur with weight- 
bearing. All patients usually returned to duty in 8 weeks. No displacement 
of any of these fractures was noted. 

During the period of this study 203 diagnoses of stress fractures of bones 
other than the calcaneus were made. These fractures were located in the upper 
and lower parts of the fibula or tibia, nnetatarsals, obturator ring, and femoral 
neck. It is estimated from out-patient records that calcaneal fractures repre- 
sent 19% of all stress fractures seen, some — metatarsal and fibular — not being 
hospitalized. 

Stress fractures of the calcaneus may be diagnosed as a more serious 
condition — such as rheumatic fever, arthritis, or neurosis — which occasionally 
may lead to medical discharge. 

Modification of some factors of the initial period of recruit training did 
not result in reduction of incidence of stress fractures, and such measures as 
shoe corrections, heel lifts, or sponge rubber pads were of no advantage. It 
was concluded that a short graduated training period prior to routine recruit 
training is indicated. (LT J. W. Leabhart MC USNR, Stress Fractures of the 
Calcaneus: J. Bone & Joint Surg. , 41-A : 1285-1290, October 1959) 

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Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget (19 June 1958). 



Medical News Letter, Vol. 34, No. 11 



Bell's Palsy 

Currently there seems to be general agreement that Bell' s palsy is the 
result of reduced blood flow to the facial nerve with the usual effect of anoxia- 
edema. Dysfunction of the autonomic nervous system resulting in spasm, 
thrombosis, or embolism in the vessels supplying blood to the nerve is con- 
sidered to be a reasonable explanation. Because the facial nerve is enclosed 
in a rigid bony canal the "timnel syndrome" is produced with a vicious circle 
of vasospasm,, anoxia, edema, and pressure on vessels with further anoxia. 

Mild facial paralysis with minimal or no electrical changes lasts 2 to 4 
weeks. With complete degeneration of the facial nerve there is never a return 
to completely normal power to move individual muscles of the face on the 
affected side. Contracture of muscles on the affected side might result from 
overstimulation of these muscles so that complete relaxation is not obtained 
and the muscles gradually shorten. Another conamon sequela is the appearance 
of hemifacial spasm on the affected side. It appears that 10 to 15% of patients 
who have had Bell's palsy have a persisting deformity which is cosmetically 
and psychologically of major importance to the patient. 

It seems, therefore, that if some method of screening could be found 
to separate patients without complete degeneration from those with it, the 
possibility of coming to a decision as to line of treatment could be furthered. 
Unfortunately, it is impossible to foretell when degeneration of the neuraxon 
will take place. Two weeks is the critical period. If signs of beginning recov- 
ery are not evident at the end of this time, it is reasonable to assume that 
degeneration has taken place and it can usually be demonstrated. 

This dilemma faces the physician treating a patient with Bell's palsy: 
Will neurolysis of the facial nerve before the end of the first week be for the 
greatest good of the greatest number, or should neurolysis wait until degen- 
eration becomes evident? Considering morbidity and undesirable results of 
unnecessary surgery, the author has adopted the rule that if no sign of begin- 
ning regeneration is indicated by electromyography after two months, the 
facial nerve should be decompressed. 

Muscles deprived of their nerve supply become flaccid and undergo pro- 
gressive atrophy. Wasting is most rapid in the early stages after injury and 
is more rapid in young subjects. As the muscle fibers shrink, fibrous tissue 
proliferates. If reinnervation occurs before the fibrosis is complete, atrophic 
changes are reversible, but the greater the interstitial fibrosis the less the 
ultimate recovery. Muscle atrophy is accelerated by chronic overstrecthing 
which is brought about by pull of muscles of the sound side and by gravity. 

Stretching of muscles attached to the upper lip can be controlled by an 
intraoral splint. Electrical treatment should be extremely delicate because 
badly directed electrotherapy will end in increased contracture. Galvanism 
begun as early as possible after onset retards atrophy and helps maintain 
contractility. There is no evidence that intravenous infusions of procaine or 



10 Medical News Letter, Vol. 34, No. II 



histamine are beneficial in diminishing incidence of sequelae or speeding 
recovery. Some reports indicate that steroids may be of benefit but must be 
considered with skepticism. 

Exercise should be prohibited until there is clinical evidence of active 
movements because overaction of the sound side increases the stretching of 
paralyzed muscles. When voluntary movements become visible, exercises 
should be carried out with the sound side firmly controlled by the hand so that 
the weak recovering muscles can act without having to work against too strong 
a pull. 

The surgical technique preferred by the author, when neurolysis is 
indicated, is described. (Williams, H. L. , Bell's Palsy: A.M. A. Arch. 
Otolaryngol., J70_: 436-443, October 1959) 

Transfusion of Cadaver Blood 

In 1928, V.N. Shamov, a Soviet Surgeon, proved that dogs subjected 
to profuse bleeding could be revived if the blood of recently killed dogs was 
transfused to them. In March 1930, S. S. Yudin of the Sklifosovsky Institute 
in Moscow successfully performed transfusion of cadaver blood to a patient 
who had lost a considerable amount of blood. Thus, the 1,000-year belief 
that cadaver blood is poisonous was refuted. It was discovered that cadaver 
blood not only preserved its sterility for several hours after death, but re- 
mained functionally effective. 

Thirty years have passed and the method of cadaver blood transfusion 
has firmly established itself in the practice of the Institute where it was first 
applied to man. Many facts relative to cadaver blood have been established. 

It has been proved that the capacity of the blood as oxygen carrier is 
preserved for 6 to 8 hours after death. Leukocytes retain their phagocytic 
function during the first 10 hours after death. The blood of those dying 
suddenly does not coagulate at all, or after an initial coagulation, rapidly 
dissolves again and remains liquid — the phenomenon of so-called fibrinolysis. 
It has also been proved that blood withdrawn from cadavers never includes 
that which flows from the intestinal tract into the portal system, nor does it 
include blood flowing from the parenchynna of the lungs. The morphologic and 
biochemical composition of stored cadaver blood proves to differ very little 
from the stored blood of living donors. 

The Sklifosovsky Institute maintains an operating room served by med- 
ical teams consisting of physicians, nurses, and assistants who are on duty 
day and night. The cadavers of persons dying suddenly from heart failure of 
many types are considered most suitable for procuring blood. The cadavers 
of individuals dying as a result of accidents are not suitable as a considerable 
amount of blood flows out of the damaged tissues which creates the danger of 
infection. 



Medical News Letter, Vol. 34, No, 11 11 



Blood is withdrawn frora the left jugular vein by means of two cannulae, 
one in the direction of the heart, the other in a cranial direction. Gravity 
flow results in yield of Z to 3 liters of undiluted blood. Stabilizer is not 
required, but glucose -phosphatic solution with antibiotics is added in order 
to prolong conservation of the blood. When the maximum quantity of undiluted 
blood flows out, the collection of washed-out blood is accomplished, using 
1, 000 ml. of glucose -phosphatic solution introduced into the carotid artery. 

The collected. blood is kept in a refrigerator until the final results of a 
nunaber of thorough laboratory tests are known. These include blood grouping; 
culture studies; examination of a thick drop for Plasmodium of malaria; deter- 
mination of hennoglobin, cholesterin, and rhesus factor; general clinical ana- 
lysis; and, in some cases, analysis for latent henaolysis and fragility of 
erythrocytes. The cadaver additionally is subjected to careful autopsy study 
involving thorough macroscopic and microscopic examinations. Only when 
all results prove favorable is the blood released for clinical use. 

During 28 years, more than 27,000 transfusions employing cadaver 
blood have been performed — the amount has totaled 25 tons. Cadaver blood 
has comprised 70% of the requirennents of the clinics of the Sklifosovsky 
Institute for blood transfusion. Experience has proved that cadaver blood is 
not only harmless with, respect to infection or intoxication, but possesses a 
number of advantages over blood of living donors. These are: 

1. Owing to the proper selection of cadavers for blood collection, obser- 
vance of strict asepsis, organization of serologic and bacteriologic control, 
euid thorough pathologicoanatomic examination of the cadavers during autopsy, 
the recipient is afforded ample safeguards against transmission in the trans- 
fused blood of any diseases, toxins, or pathogens. Such safeguards cannot be 
assured when blood is obtained from living donors, 

2. The presence of the phenomenon of fibrinolysis in cadaver blood 
removes the need for citrate which is an advantage when several liters of 
blood are required for one patient. Generally, cadaver blood elicits less' 
reaction than blood of living donors. 

3. The volume obtained from one cadaver makes it possible, when need- 
ed, to transfuse one patient with a considerable amount of the same blood, re- 
ducing the risk of incompatibilities incident to blood from multiple sources. 
Additionally, plasma may be subjected to separation by gravity and such plasma 
may be preserved for long periods. 

Methods of cadaver blood transfusion deserve further elaboration and 
wider application. 

In connection with the result of development of Soviet scientific thought, 
the well-known British Lancet once wrote: "Reason has triumphed over instinct. " 
{B.A. Petrov, Transfusion of Cadaver Blood: Surgery, 46: 651-655, October 
1959) 

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12 Medical News Letter, Vol. 34, No, 11 



Endocrine s and Peptic Ulcer 

During the past few years there has been increasing evidence suggest- 
ing that gastric secretory activity may be influenced by endocrine as well as 
neurogenic factors. Stress may be mediated to the stomach not only by the 
vagus nerve, but by a purely hormonal mechanism transmitted through the 
hypothalamic -pituitary-adrenal pathway independent of the vagus nerve or 
gastric antrum. Thus, gastric and peptic glands may be integrated into the 
general endocrine system because it is accepted that intestinal ulcef-ation with 
hemorrhage or perforation is an integral part of the alarm reaction. 

Studying the effects of corticotropin and adrenal steroids upon the sto- 
mach, many investigators present conclusions to indicate that the adrenal 
steroids (1) increase gastric acid and pepsin in the human being and in ani- 
mals; (2) increase tissue, plasma, and urinary pepsinogen; (3) decrease the 
mucus protective barrier; and (4) interfere with tissue repair. Effects upon 
gastric parietal cell mass and vascularity remain to be determined. 

There is considerable controversy concerning the relation of the adrenal 
cortex to peptic ulcer disease. It seems clear that patients with adrenal insuf- 
ficiency demonstrate low gastric secretory activity and rarely develop peptic 
ulcer, whereas patients receiving adrenal glucocorticoids over a long period 
of time are subject to high gastric secretory activity and development of a 
new peptic ulcer or reactivation of a previously healed ulcer. The mechanisna 
of ulcer production during adrenal steroid administration is not clear. The 
fact remains that gastric or duodenal ulcers developing during adrenal steroid 
administration heal on antacid therapy despite continued administration of 
adrenal glucocorticoids, emphasizing the importance of the acid peptic factor. 

Certain fornns of physical stress as that induced by myocardial infarc- 
tion, burns, surgery, trauma, shock, and pain may induce an increase in 
gastric secretory activity — often to ulcer levels — paralleled by an increase 
in adrenal cortical activity. There appears to be an increased incidence of 
peptic ulceration with hemorrhage or perforation following cardiac surgery 
coincidental in time with the anticipated maximal adrenal response to the 
surgical procedure. 

Significance of endocrine factors in peptic ulcer disease is amplified 
by reports of peptic ulceration with marked gastric hypersecretion associated 
with multiple endocrine tumors involving the pituitary, adrenal, and parathy- 
roid glands and non-insulin producing islet cell tumors of the pancreas. 
Adrenocortical hyperplasia is connmon in this syndrome. 

Adrenal hormone is presumably essential for normal gastric secretory 
activity, without which peptic ulcer does not occur. In the presence of excess 
adrenal hornaone, however, gastric and duodenal mucosa might be sensitized 
and excessively responsive to ulcerogenic influences which ordinarily could 
not induce ulceration in accordance with the "permissive" concept of adrenal 
action. Hypersecretion itself may be a reflection of this increased gastric 



I 



Medical News Letter, Vol. 34, No. 11 13 



sensitivity to excess adrenal horraone. Adrenal steroids, moreover, may 
potentiate vagal influences upon the stomach, or the adrenal gland of the peptic 
ulcer patient may be more sensitive to stimulation with a resultant exaggerated 
adrenal or gastric response. Under basal conditions, the stomach acts semi- 
autonomously relative to the adrenal cortex, but following corticotropin stim- 
Illation, gastric peptic secretory activity comes more directly xinder adrenal 
dominance. {Gray, S. J., Present Status of Endocrine Influences Upon the 
Stomach and Their Relationship to Peptic Ulcer Disease: Gastroenterology, 
37 ; 412-420, October 1959) 

* * * * ?l= * 
Making Sense 

NOTE: This condensation does not do justice to the published lecture. All 
are urged to obtain the journal for leisurely reading of the author's enjoyable 
and thought provoking comments on semantics. Editor) 

The meaning of words has a profound effect on the progress of medicine: 
for words, though they provide a vehicle by which thought can travel, seldom 
allow it to arrive intact at its destination. 

It is pleasant to believe that the facts of clinical medicine exist quite 
independently of the names bestowed upon them, but this is not so. In clinical 
medicine it is not only a matter of finding words to fit the facts, but often of 
finding facts to fit the words. When christening. a disease, we wait for the 
name to be born and then we find a disease for it. 

There is something about a name — particularly an eponymous term — 
which brings into being things which never seemed to be there before — such 
as Pel -Eb stein fever. Does this phenomenon really exist? I think it very 
unlikely indeed. Yet if one case of Hodgkin's chanced to run such a temper- 
ature, the news would soon travel round. 

It does not matter whether or not Pel-Ebstein fever exists, my conten- 
tion remains the same: the bestowal of a nanne upon a concept — whether real 
or imaginary — brings it into clinical existence. 

A good example of creation beginning with the word is gallstone colic. 
There is no such thing. Gallstone pain steadily climbs to an agonizing peak 
without any fluctuation and then passes off. But so firmly has the label colic 
been stuck onto this pain that the pain is expected to be colic, assumed to be 
colic, believed to be colic, and finally bullied into being colic, and a patient 
with gallstone pain will be described as having colicky pain however steady it 
may be. 

Contrariwise, a condition without a descriptive term has far less chance 
of clinical recognition. In untreated pernicious anemia there is often quite a 
high fever. This ustially settles to normal levels within two or three days after 



14 Medical News Letter, Vol. 34, No. 11 



an adequate dose of vitamin Bi2* 1 assert that had it been called the Addison- 
Castie fever or hypocyanocobalaminic fever every medical student in the 
land would have heard of it, many doctors would be afraid to diagnose per- 
nicious anemia without its presence, and the proportion of patients with this 
fever would rise sharply once the name got into nurses' textbooks. 

A symptom pattern may seem to exist, yet, because it has no name, 
it has no clinical existence. Whether it should be named, I am unable to say. 
The naming of diseases ought not to be undertaken lightly. A fertile medical 
author can easily beget a large clinical progeny; but some of his youngsters 
may turn out to be illegitimate, and with others there may be doubt about 
their paternity. 

A special kind of disease -naming is done by those branches of industry 
whose sales depend largely on the planned creation of nonexistent diseases, 
such as night starvation, hidden hunger, and tired blood. In this highly crea- 
tive and imaginative work the importance of a good name cannot be exaggerated. 
We do not know how many bowel neuroses are initiated by relentlessly per- 
suading the public into vain strivings after inner cleanliness, 

I have only once named a disease and that was Munchausen's syndrome. 
I discovered nothing about it; I only described something that most doctors 
knew already and gave it a name. Yet the effect of christening it astounded nne. 

There are many syndromes that have no name. For instance, there is 
no name for an unexplained bout of fever and malaise lasting two or three 
days and commoner in children than in adults. The layman calls this "flu, " 
but the doctor, who correctly prefers to reserve this term for the pandemic 
condition caused by an identifiable virus, is powerless when faced with this 
condition. "F. U. O. " is properly reserved for more lengthy fevers. In the 
physician's home, when one of his family gets it, he may be driven by sheer 
nomenclatural bankruptcy to call in a colleague to show his wife that another 
doctor cannot do any better. 

Thus, words perpetuate illnesses, syndromes, and signs whose existence 
is doubtful, deny recognition to others whose existence is beyond question, and 
distort textbook descriptions to conform to the chosen word. 

An ancient and important property of names is that they give to those who 
know them a feeling of power over what is named. However uninformative the 
name of his illness may be, a patient feels his foe is partially vanqxushed once 
he knows its name. 

The significance of words to our patients is a subject on which system- 
atic research could gainfully be pursued. Arthritis appears to portend a pro- 
tracted and crippling disease which will leave a man deformed and helpless, 
whereas rheumatisna betokens a few aspirins, a bottle of liniment, and back 
to work next week. But names give comfort as often as despair, providing an 
illusion of clarity where there was mystery and giving a tangibility to illness 
which makes it more likely to be overcome. This applies both to patients and 
to doctors. 



Medical News Letter, Vol. 34, No. 11 15 



The study of meaning is a subject so surrounded with difficulties and 
contradictions that few people dare speak about it confidently. When we use 
a word it has to mean the same to us as it does to the person we are address- 
ing or else our thoughts are not transmitted intact. Consider the meaning of 
meaning as it applies to some words in the medical vocabulary. There is the 
etymological meaning, the implicational meaning (notions either true or false 
upon which the etymological meaning is based), and the referential meaning. 
Consider the words meconium and micturition from these three aspects. 
Much confusion results. Once a word has been mishandled consistently, it is 
useless for scholars to try to preserve its correct meaning. 

The importance of keeping words undamaged by handling them carefully 
and putting thenn in the right place only is one that needs underlining. We have 
said lymph "gland" so long that the word "node" is becoming a pedantic inter- 
loper. Wb use hemiplegia and hemiparesis so carelessly that their nice dis- 
crimination can no longer be preserved. Again, "aphasia" nowadays gives no 
idea whether speech defect is gross or mild. 

Which, then, is the true meaning of a word: Is it the dictionary definition 
or the sense in which it is used? There is no answer to this question because 
it depends on what you mean by the true meaning of a word. 

What other troubles arise from words? Consider that deceptive but 
convenient no\m — the word "mind. " Because it has been christened with a sub- 
stantive it is easy to think of it as possessing substantival size or shape or 
substance. The mind has no more existence than the sight, hearing, or diges- 
tion; it is much more a process than a thing. Attempts are made to partition 
it as if it were as solid as a boarding-house, and psychiatric architects erect 

jerry-built cubicles within it. 

Widely collective abstract words are dangerous. An example is the 
expression "juvenile delinquency. " This embraces every kind of antisocial 
behavior from stealing a few apples from an orchard to bludgeoning an old 
lady to death. Are we not guilty of much the same thing if we use the word 
"stress" to ennbrace all the thousand natural shocks the flesh is heir to? 

Many words in the nnedical vocabulary are unnecessarily confusing. A 
technical term should clarify and not conceal meaning. Jaundice transnn.itted 
by serum is never likely to be confused with that caused by giving serum from 
a different animal; the name "homologous seruna jaundice" is ridiculous. 

Long words and esoteric terms have no place in scientific writings except 
when they convey more than their shorter equivalents, or in instances of con- 
cealing something hurtful from a patient. Yet, technical words are often used 
which add little information and befog the puzzled minds of those who read them. 

I warn you of a new kind of jargon whose cotton-wool coils are being 
wrapped closer around us every day — the jargon of officialdom and the jargon 
of committees. In this malignant hypertrophy of language, nobody says any- 
thing, they "state" or "intimate that. " They never think, they "are of the 
opinion that. " Nobody finishes anything, it is "duly completed. " 



16 Medical News JLetter, Vol. 34, No. 11 



If I have done anything to convince you that words can either stifle or 
stimulate the march of science by their choice and their use, I am weD con- 
tent. As Stevenson says: "Bright is the ring of words when the right man 
rings them. " {Asher, R. , Making Sense: The Lancet, 7099 : 359-365, 
19 September 1959) 

Association of Military Surgeons 
Elects Officers and Presents Awards 

Rear Admiral Richard A. Kern MC USNR (Ret) was elected President 
of the Association of Military Surgeons of the United States for I960 at the 
Association's Annual Business Meeting, 9 November 1959, the first day of 
its 66th Annual Convention. The Association, organized in 1891 and incor- 
porated by Act of Congress in 1903, is devoted to the advancement of all 
phases of medicine as related to the Federal services. It represents all as- 
pects of, and all professions in, the medical services of each Federal agency. 

Other officers include: Leroy E. Burney, M. D. , Surgeon General of 
U.S. Public Health Service^First Vice President; Major General James P. 
Cooney MC USA — Second Vice President; and Rear Admiral C. B. Galloway 
MC USN, Assistant Chief for Research and Military Medical Specialties, 
Bureau of Medicine and Surgery — Third Vice President. 

Admiral Kern received his M. D. from the University of Pennsylvania 
in 1914. After internship and medical residency in the Hospital of the Univ- 
ersity of Pennsylvania, he remained as a member of the staff of that hospital. 
In World War I he served as a Lieutenant in the Medical Corps of the Navy, 
most of the time aboard the USS SOLACE in the Atlantic. After the war he 
returned to the University of Pennsylvania and eventually became Professor 
of Clinical Medicine in 1934. 

Commissioned in the U.S. Naval Reserve in 1925, Admiral Kern was 
active in the progrann^ and was called to active duty in 1942, together with other 
members of Medical Specialist Unit #31, which he organized in 1935. After 
extensive duties in the Pacific area for which he received a Letter of Commend- 
ation with Ribbon he returned to the United States and became Chief of Medical 
Service and Rehabilitation Officer, U, S, Naval Hospital, Philadelphia, Pa. , for 
which services he received another Letter of Commendation. 

Released to inactive status in 1946, Admiral Kern returned to the Univ- 
ersity of Pennsylvania as Professor of Clinical Medicine. In 1947, he was named 
Officer in Charge of the newly reactivated Volunteer Medical Division #4-3, 
U.S. Naval Reserve, and has subsequently rennained vitally active in all phases 
of military medicine and the Naval Reserves, In 1946, he became Professor of 
Medicine and Head of the Department in the School of Medicine, Temple Univer- 
sity, and has been serving as Professor of Medicine, Emeritus, since 1956. 



Medical News Letter, Vol. 34, No. 11 17 



Beginning in 1948, Admiral Kern has been sent by various services on 
numerous trips as Expert Civilian Consultant to all zones of m.ilitary activities. 
Since 1951, he has been Chairman of the Committee on Naval Medical Research, 
National Research Council, and Chairman of the Panel on Shipboard and Sub- 
marine Medicine, Research Development Board, Department of Defense, He is 
Chairman of the Advisory Panel on Medical Sciences, Office of the Assistant 
Secretary of Defense (Research and Engineering); member of the Board of 
Honorary Civilian Consultants to the Surgeon General of the Navy; and other 
Department of Defense and Navy committees. 

Admiral Kern is editor of the American Journal of Medical Sciences, and 
a member of the Joint Commission on Accreditation of Hospitals. He has held 
several offices in the American College of Physicians, being President in 1957, 
and was First Vice President of the Association of Military Surgeons for 1959. 

At the Honors Night Dinner, the last day of the convention, various awards 
were presented. Annong the recipients was Vice Admiral Thomas F. Cooper 
MC USN (Ret) who was one of three presented the Founder's Medal for outstand- 
ing contribution to military medicine and for meritorious service to the Assoc- 
iation. Admiral Cooper recently retired from active duty after having served 
as Commanding Officer of the National Naval Medical Center. 

Another recipient of awards was Robert Van Reen, Ph. D. , Biochemist 
and Associate Head, Dental Division, Naval Medical Research Institute, Beth- 
esda, Md. who received the McJLester Award, consisting o£ a bronze plaque 
and honorarium of $500, made annually by the J. B. Roerig Company Division, 
Charles Pfizer and Company, Inc. , for outstanding achievennents in the field 
of nutrition. 

In addition to representatives of the medical services of all Federal 
agencies in the United States, approximately 55 international delegates from 
45 countries attended the convention. The 67th Annual Convention will be held 
in Washington, D. C. next year, 31 October, 1 and Z November. 



Examination, Part II 
American Board of Obstetrics and Gynecology ' 

The next scheduled examinations (Part II), oral and clinical, for all can- 
didates, will be conducted by the entire Board at the Edgewater Beach Hotel, 
Chicago, 111. , 11-16 April I960. Formal notice of the exact time of each 
candidates's examination will be sent in advance of the examination dates. 

Candidates who participated in Part I examinations will be notified of 
their eligibility for Part II examinations as soon as possible. 

Current bulletins of the American Board of Obstetrics and Gynecology, 
outlining requirements for application, may be obtained from the Secretary: 
Robert L. Faulkner, M. D. , 2105 Adelbert Road, Cleveland 6, Ohio. 



Medical News Letter, Vol. 34, No. 11 



Public Health Training in Civilian Institutions 

A limited number of medical officers will be sponsored for postgraduate 
training in public health beginning in the summer and fall of I960. In view of 
the need for early commitment with civilian institutions, interested medical 
officers are urged to submit their requests for training to the Bureau of 
Medicine and Surgery prior to 31 December 1959. 

Successful completion of postgraduate training leading to the degree of 
Master or Doctor of Public Health will satisfy academic requirements for 
certification by the American Board of Preventive Medicine. 

Among the interesting assignments available to medical officers who 
complete the training are: preventive medicine units ashore, both in the United 
States and overseas; medical research units; preventive medicine duties at re- 
cruit training centers; the Bureau of Medicine and Surgery; and various naval 
schools as instructors in such subjects as epidemiology, environmental health, 
preventive medicine, and related laboratory sciences. The broad knowledge 
and experience to be gained in a successful career in public health in the Navy 
provide outstanding preparation for the responsibilities to be assumed with 
advancement in rank through senior grades. 

Applications from naedical officers for training in public health should be 
nnade by official letter to Chief, Bureau of Medicine and Surgery, via the chain 
of command, and should include the obligated service agreement stipulated in 
BuMedlnst 1520. 7B. Applications from active duty Reserve Medical officers 
will be considered provided that application for commission in the Regular 
Navy is submitted at the same time. Final approval of Reserve applicants for 
training will be conditioned upon acceptance of a Regular Navy commission when 
tendered. 

Individuals may indicate three choices of institutions in the order of pref- 
erence as to where they desire the training. However, the Bureau of Medicine 
and Surgery will make final arrangements for enrollment after Bureau approval 
of the request has been obtained. 

"?* *? 'T* "r T' 1P" 

Section of Military Pediatrics 
Formed by American Academy of Pediatrics 

In conjunction with the annual meeting of the American Academy of 
Pediatrics, the first meeting of the Section of Military Pediatrics was held in 
Chicago on 7 October 1959. Forty-five military pediatricians became charter 
members, and elected as their Chairman, CAPT W.I. Neikirk MC USN, 
presently stationed at U. S. Naval Hospital, Philadelphia. CDR F. B. Becker 
MC USN, U.S. Naval Hospital, Portsmouth, Va. , was elected to the committee, 
along with representatives of the Army, Air Force, and Public Health Service. 



Medical News Letter, Vol. 34, No. 11 19 



The designated purpose of the section is to study problems encountered 
in pediatrics in the Armed Forces, and to develop programs for civilian and 
military management of mass casualties among the pediatric population of the 
nation. 

All interested service physicians dealing with children are invited to 
contact any committee memiber for further information related to the section 
and its function; and constructive suggestions for long and short term projects 
that may be sponsored by such a section are invited. 

^ ^C ^ ^jf ^ !^ 

From the Note Book 



Captain Amberson at Eaton Laboratories . CAPT J.M. Amberson MC USN (Ret) 
heads the international clinical research program for Eaton Laboratories, 
Norwich, N. Y. , after long and varied experiences in the Navy which included 
a trek through the length of Africa in a one -year study of trypanosomiasis and 
other tropical diseases, and experiences as chief medical officer in charge of 
"Passage to Freedom" in which over a million Vietnamese were voluntarily 
evacuated from communist occupied territory after the fall of Dien Bien Phu. 

(TIO, BuMed) 

Japanese Interns at USNH, Yokosuka . Competitive examinations were given 
to Japanese medical students on Z November 1959 to select 14 new MD's who 
will serve one-year internships at the U.S. Naval Hospital, Yokosuka, Japan, 
to begin on 1 April I960. They will receive training comparable to that 
received in the U. S. and will undergo many hours of rigorous didactic instruc- 
tion from. Naval Medical officers who are specialists in each clinical field, 

(TIO, BuMed) 

CDR Weldon Presents Paper . CDR Robert B. Weldon DC USN, Senior 
Dental Officer on board the USS CASCADE, recently presented a paper en- 
titled "Maxillofacial Prosthetics" before the Newport Dental Society, Newport, 
R. 1. 

Choncrosarcoma; Ca of Thyroid . National Cancer Institute, National Institutes 
of Health, is undertaking study of effects of large doses of Sulfur -35 radiation 
on patients with inoperable but biopsy-accessible chondrosarcoma; and study 
of hormonal influences and uptake of radioiodine in relation to tumor structure 
and detection of autoimmune antibodies of carcinoma of the thyroid. Physicians 
who may wish to refer patients may communicate with Dr. Charles Zubrod, 
NCI Clinical Director, Bethesda 14, Md. (Washington Report on the Medical 
Sciences, 16 November 1959) 



20 Medical News Letter, Vol. 34, No. 11 



Influenza Epidemic in Chile . The World Health Organization has received 
information that an epidemic of A2 type influenza occurred in Chile during 
August and September. Although the outbreak was less severe than that of 
1957, there have been 200 to 300 deaths. (PHS, Dept. of H. E. W. ) 

"Precordial Catch" Syndrome. Evaluation of a series of patients with a dis- 
tinctive anterior chest pain syndrome — "precordial catch" — indicates that 
the main characteristics are severe, sharp pain, occurring at rest or during 
mild activity, located near the cardiac apex, and lasting from one -half min- 
ute to five minutes. It is a benign syndrome which requires differentiation 
from anterior chest pains of organic significance. (A.J. Miller, T.A.Texidor, 
Ann. Int. Med. , September 1959) 

Occult Cholecystitis . This report from the Mayo Clinic contributes emphasis 
to a policy of prophylactic surgery. The occasionally insidious and occult 
development of acute cholecystitis, even of perforation of the gallbladder, 
argues for cholecystectomy without undue delay once the presence of gallstones 
has been detected. (J. Gross, J. Waugh, Postgrad. Med. , September 1959) 

Parkinson's Disease . A comprehensive review of this disturbing disease is 
presented with emphasis on various aspects of management. The authors con- 
tend that any real treatment must be the result of constant cooperative work 
between the internist, the surgeon, and the laboratory, with important assists 
from the psychiatrist and physical therapist. (A, C. England, Jr., A.M. A. 
Arch. Int. Med. , September 1959) 

Splenic Pulp Manometry . Splenic manometry might yield valuable diagnostic 
information as to the presence or absence of varices in patients bleeding 
acutely from the upper gastrointestinal tract. The procedure is relatively 
simple, direct, practical, and safe. {W. Panke, et al. , Surg. Gynec. and Obst 
September 1959) 

Antibody Treatment of Tumors . A highly concentrated preparation of anticancer 
antibodies was isolated. The proteins thus obtained were stored and activity 
of the fraction was tested when it was injected at the same time as cancer cells 
and also injected in animals with already established tumors. A similar pro- 
cedure was performed for three patients suffering from advanced carcinoma of 
the breast, with clinical indications of regression. (P. Buinauskas, et al. , 
A.M. A. Arch. Surg., September 1959) 

Bariuni in Bronchography . The advantages of employing barium sulphate and 
methylcellulose as contrast media in bronchography, using physiologic saline 
as a vehicle, include: opacification of the whole bronchial tree without pen- 
etration into alveoli; ready elimination by ciliary action and by coughing; 



• i 



Medical News Letter, VoL 34, No. 11 21 



absence of toxicity; tolerance of respiratory mucous membrane; and, great 
decrease in expense. {J. Teixeira, L. C. V. Teixeira (Brazil), Dis. Chest, 
September 1959) 

Needle Biopsy of Liver. Reporting from the University of Perugia, Italy, 
Dr. Giorgio Menghini describes a modification of the technique for needle 
biopsy of the liver which decreases the attendant hazard and length of time 
required to make the biopsy, and involves two operators. M. D. Small, et al. , 
in the following article describe their experiences in employment of the 
Menghini needle and technique. (Am. J. Digest, Dis. , September 1959) 

Medical Aspects of Traffic Safety. A comprehensive symposium on the med- 
ical aspects of traffic safety and related injuries comprises the first section 
of the October American Journal of Surgery. Topics range from "The Medical 
and Civic Responsibilities of the Physician in the Prevention of Automobile 
Injuries and Deaths" and "Preliminary Management of Traffic Casualties" to 
"The Teaching of Trauma in Medical Schools" and "What is the Profit in Driver 
Education?" 

Variant Forna of Angina Pectoris . This syndrome, differing from classic 
angina pectoris, is not brought on by increased cardiac work, is usually more 
severe and of longer duration, often waxes and wanes, often occurs at about 
the same time each day, and is not relieved by rest. Aspects of diagnosis are 
presented, and treatment with nilidrin hydrochloride and anticoagulants are 
indicated. (M. Prinzmetal, et al. , Am. J. Med. , September 1959) 

STG Test for Liver Function . The serum thromboplastin generation (STG) test 
reveals a defect in the majority of patients with known liver disease and in about 
50% of patients with suspected liver disease in whom the standard liver function 
tests are normal. This abnormality is believed to be compatible with the one 
attributed to factor X deficiency. The authors consider that the test may be of 
value as a liver function test. (S. F. Rabiner, T. H. Spaet, Ann. J, Med. Sci. , 
September 1959) 

Genitourinary Tuberculosis. Reviewing 100 consecutive cases of active pulmon- 
ary tuberculosis admitted, only 2 wer^ found to have genitourinary tract involve- 
ment. The present day chemotherapeutic treatnaent and early case finding of 
pulmonary tuberculosis have materially changed the course of the disease as 
well as the incidence of genitourinary tuberculosis. (C. Kuenh, W. Gehron, Jr. , 
J. Urol. , September 1959) 

Mosquitoes of Medical Importance - a newly published 158-page handbook, is 
obtainable at no charge from Entomology Research Division, Agricultural 
Research Service, U.S. Department of Agriculture, Washington 25, D. C. 
(Washington Report on the Medical Sciences, 16 November 1959) 



22 Medical News Letter, Vol. 34, No. 11 




UEMTAl 1.1^^1 SECTION 



U.S. Navy - New Zealand Joint Dental Investigation 

Upon the invitation of His Excellency, the Prinie Minister of New Zealand, 
The Right Honorable "Walter Naoh,P. C. , RADM C. W. Schantz DC USN, Assistant 
Chief, Bureau of Medicine and Surgery (Dentistry) and Chief of the Dental 
Division, recently met with the Prime Minister at the Embassy of New Zealand 
to discuss a research project being conducted by CAPT F, L. Losee DC USN 
as coprincipal investigator with Dr. G.N. Davies of the University of Otago 
Dental School, Dunedin, New Zealand. ADM Schantz was accompanied in his 
visit with the Prime Minister by CAPT C.A. Ostrom DC USN who represented 
the Commanding Officer of the Naval Medical Research Institute, National 
Naval Medical Center, Bethesda, Md. 

CAPT Losee is attached to the Naval Medical Research Institute and is 
currently on an extended field assignment at the request of the New Zealand 
government to direct the investigation titled "New Zealand Dental Caries and 
Soil Relationship. " Extensive preliminary clinical surveys of the incidence 
of dental caries in children of certain communities indicated a strong influence 
by regional soil types. This research was designed to determine the relation- 
ship between trace elements in soil, pasture, food, and water of selected areas 
to trace elements in urine, bones, and teeth of sheep; and in urine and extracted 
teeth of children living in those areas. Resultant findings will be related sub- 
sequently to the clinical dental condition of children living in the areas. The 
first year of investigation led to selection of two pairs of communities where 
caries incidence is lower, and in which trace element contents of locally grown 
vegetables appear elevated in molybdenum, aluminum, and titaniurn, and lower 
in copper, manganese, barium, and strontium. 

The Prime Minister expressed his government's appreciation to the 
United States Navy Dental Corps for the part it is taking in the program. 

;{; ^ # ;jc ^ :s!; 

TV Optical System for Dental and Medical Use 

A new optical fiber probe and closed circuit TV system that will permit 
viewing of the inside of the patient's mouth, highly magnified, on a TV screen 
has been successfully demonstrated at the U.S. Naval Dental School, Bethesda, 
Md. The device eventually can be adapted for medical probes to explore inside 
the human body. It has been developed under a feasibility study sponsored by 



Medical News Letter, Vol, 34, No. 11 23 



the Office of Naval Research and carried out by Avco Corporation at Wilmington, 
Mass. 

RADM Bartholomew W. Hogan, Surgeon General of the Navy, stated: 
"The Navy supported this program because we desired to find out whether this 
promising new principle would actually work in practice. The research done 
so far has demonstrated that television can be very useful in dental procedures 
and offers the promise of significant improvement in dental training. Also, with 
further development, this technique may permit us to review the inside of other 
body cavities, highly magnified and in color, with the picture accessible to 
many persons — perhaps doctors, nurses, and students — simultaneously. " 

TV canneras are now used in limited dental application, but are imprac- 
tical. They can view only part of the mouth, present a difficult lighting prob- 
lem, and cause discomfort to both patient and dentist because of their size. 

The optical probe system being developed at Avco consists of a bundle 
of optical fibers wound together in a small whip-like cable with a fingertip- 
size lens arrangennent at the probing end, coupled to a closed-circuit TV cam- 
era at the other end. A bundle contains up to 10,000 of the hair-like fibers. 
Each tiny fiber picks up light from a microscopic section of the surface in 
front of it, and transmits the speck of light to the other end. With thousands 
of the fibers bound tightly into a cable, a picture made up of the thousands of 
light segments can be sent from the lens inside the patient's mouth to the TV 
camera and from there to the screen where the tooth, or a portion of it, is 
seen magnified up to 35 times its actual size. 

This permits the dentist to display selected portions of the mouth or 
individual teeth during actual operative procedures for simultaneous inspection 
by other dentists or students. From a training standpoint, it would permit 
large classes of students to watch the procedures of an experienced practitioner. 

Successful use of the new system in "endoscopes" would be a great step 
forward over any current technique. The flexible probe could reach and illum- 
inate areas not now accessible. It could display these areas for inspection by 
several specialists for immediate consultation and diagnosis. It would render 
surgical operations highly visible to students, who now must rely almost en- 
tirely on the surgeon's running commentary for an understanding of the operation. 

Since the fibers can transmit light in both directions, they could also be 
used to bring in light from a remote source without electrical wires. This means 
that body cavities could be illuminated for inspection or treatment without the 
hazard of electrical sparks in the presence of an explosive anesthetic. 

The use of fiber optics for transnaitting light has been under exploration 
at various places in the United States and Europe for many years, and their 
application to medical probes has also been previously investigated. The 
Navy- supported Avco feasibility study, however, is the first to couple the 
fibers, lenses, and a TV camera to obtain a system permitting great magni- 
fication and simultaneous viewing. The work has been the responsibility of 
H. P. Hovnanian, head of medical science technology at Avco's Research and 



24 Medical News Letter, Vol. 34, No. U 



Advanced Development Division. Technical assistance and advice on the pro- 
ject have been provided by the U, S. Naval Dental School, National Naval 
Medical Center. Experimental optic fiber bundles were obtained from the 
American Optical Company. 



The Responsibility of Leadership 

The purpose of this article is to acquaint the Dental officer with his respon- 
sibilities as they relate to discipline in operation of the Dental Department. 
Article 1209 of Navy Regulations requires that every Dental officer in the 
naval service acquaint himself with, obey, and so far as his authority extends, 
enforce the laws, regulations, and orders relating to the Navy. In the absence 
of instructions he must act in accordance with public interest and in conform- 
ity with the customs of the Navy. It follows then that every Dental officer 
must himself set a good example of subordination, courage, zeal, sobriety, 
neatness, and attention to duty. A Dental officer must, to the utmost of his 
ability and to the extent of his authority, aid in maintaining good order and 
discipline and in promoting the efficiency of the command. 

The Dental officer who accomplishes his mission is first of all a good 
leader. He respects his men; they in turn respect him. Men follow with 
enthusiasm the directions of a real leader; they sullenly obey the orders of 
a martinet. 

A leader can be defined as one fitted by force of ideas, character, or 
genius, or by strength of will or administrative ability to arouse, incite, and 
direct men in conduct and achievement. The task of leadership is to direct 
and to unify the efforts of individuals toward achievement of common good. 
Without such guidance, the group lacks direction and decision and fails to 
make its efforts count. 

The common aim of officers and enlisted men of the Dental Corps and 
Hospital Corps, to keep alive ideals represented by the United States of 
America, will be promoted by keeping dentally fit the fighting men served by 
the unit. Men need to believe that their work is important; and it is the duty 
of the Dental officer to enliven his men as well as to enlighten them, to com- 
municate to them his own enthusiasm. 

Although the Dental officer's authority is backed by the full force of the 
U. S. Navy, the true source of ability to lead lies in himself — in the example 
he sets and in his character. Fronn the day he assumes direction of the 
department — when he impresses upon them their value to the Navy and begins 
to earn their good will — to his last day aboard, his men will judge his steadi- 
ness, his self-control, his fairness, and his decisiveness. They will observe 



Medical News Letter, Vol. 34, No. 11 25 



his integrity, humor, and loyalty; his unselfish concern for their needs; his 
courage when the going is tough; and his tenacity in completing assignments 
in spite of difficulties. If they feel secure in his leadership, they will follow 
him to the limit. 

A leader must be skilled in passing along information and in showing the 
way. Men do better work when they understand the purpose of a task and, when 
possible, have had a share in planning. The Dental officer trains his technicians, 
as with any other teacher, his success is measured partly by promotions earned 
by those he instructs. He should develop latent traits of leadership; he should 
give individuals opportunities on occasion to undertake duties of the next higher 
rate. In addition to knowing the manual and intellectual abilities of his men, he 
should know them as people. 

The Dental officer also needs the ability to organize. To foster the nec- 
essary team spirit, it is wise to set attainable objectives so that men have a 
record of successes to spur them onward during more difficult tasks. The 
first prerequisite in problenn solving is defining the task to be accomplished; 
next, acquiring all pertinent information; then breaking down the task into steps; 
finally, setting a deadline for its completion. Petty officers should be assigned 
responsibility for various phases of the total operation. This opportunity to 
assume personal direction, laying their own plans, and issuing instructions to 
their subordinates, encourages their initiative and pays dividends. 

The power to naake decisions is also vital to the leader — nothing destroys 
his influence like vacillation. The Dental officer needs first, a knowledge of 
all pertinent facts, and second, the ability to choose one course and to stick to 
that course. Confident or chaotic action by the men depends on decisiveness 
or its lack in the leader. 

In summary, the essentials of leadership are (1) character, {2) skill in 
showing the way, (3) ability to organize, and (4) power of decision. 

9^ ^ ;4; ;{: ;^ >;« 

Special Lecture at Naval Dental School 

Dr. George Christensen, oral surgeon, Brisbane, Australia, recently 
presented a lecture on "Disturbances of the Temporomandibular Joint" to the 
general postgraduate officers and members of the staff at the Naval Dental 
School, NNMC, Bethesda, Md. 

Following the lecture, Dr. Christensen conducted a round-table discus- 
sion on the temporomandibular joint and other oral surgical problems with 
staff and resident officers of the Dental School. 

Dr. Christensen is a lecturer at the Dental and Medical Schools at the 
University of Queensland and a consulting surgeon at the Repatriation Hospital 
in Brisbane. He also serves as Consultant Oral Surgeon to the Royal Australian 
Air Force, and is a Fellow of the International College of Dentists. 



26 Medical News Letter, Vol. 34, No. 11 



Serainar for Dental Reserve Commanding Officers 

Dental Reserve Commanding Officers of the 1st, 3rd, 4th, 5th, 8th, and 
9th Naval Districts recently completed a week-long seminar under the direc- 
tion of the Reserve Branch of the Dental Division, Bureau of Medicine and 
Surgery. The seminar provided indoctrination and orientation in organization, 
administration, and operation of the Dental Corps from the Bureau level and 
acquainted commanding officers with current concepts and trends affecting 
the Reserve Program with emphasis on the Reserve Dental Program. 

A series of conferences was held by commanding officers and interested 
personnel in the Navy Department with a view toward an inaproved Reserve 
Dental Program through exchange of ideas and recommendations. 

The seminar included field trips in the Washington area: a tour of the 
Pentagon and visit to the office of the Chief of Naval Operations, the Bureau 
of Naval Personnel, National Naval Medical Center, Naval Weapons Plant, 
and the National Institutes of Health. 

CAPT H.J. Wunderlich DC USNR is Head of the Dental Reserve Branch, 
Dental Division, Bureau of Medicine and Surgery. 

Dental Officers Orders 

Reporting endorsements of all Dental officers orders are required by 
the Dental Division, BiiMed. In many instances, these are not being received. 

Attention of all Dental officers is directed to the Bureau of Naval Per- 
sonnel Manual, C-5407(4) which requires that a complete copy, including 
reporting endorsennent, of all officers orders be forwarded to the Bureau of 
Medicine and Surgery following any change of duty. 

While this is a responsibility of the commanding officer, it is believed 
that the Dental officer can assist in assuring prompt forwarding of the re- 
quired copies of orders by close liaison with his cognizant personnel office. 



Policy . The U.S. Navy Medical News Latter is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be, nor 
are they, susceptible to use by any officer as a substitute for any item or 
article in its original form. All readers of the News Letter are urged to ob- 
tain the original of those items of particular interest to the individvial. 



Medical News Letter, Vol. 34, No. 11 27 




RESERVE ^m^ SECTIOIV 



Meeting of American Academy of 
Dernnatology and Syphilology 

The American Academy of Dermatology and Syphilology will conduct its 
annual ncieeting at the Palmer House, Chicago, 111. ,5-10 December 1959. 

The afternoon of 7 December will be devoted to a two and one-half hour 
round table panel on Military Dermatology with panel membership representa- 
tive of the three services of the Armed Forces, Subjects to be presented will 
include "Assessment of Metiical Emergencies and the Dermatologist, " "Special 
Problems of Submarine Medicine, " and "Medical Aspects of Survival in Polar 
Climates. " A short discussion period will follow each presentation. 

Eligible inactive Naval Reserve Medical Corps officers may earn one 
retirement point credit for attendance at this panel provided they register with 
the military representative present. 

^ ^ lV ^ tff A 

•r I* f T Tn nr* 

Publications Available to Reservists 

Bureau of Medicine and Surgery and Department of Defense publications 
which furnish information on current concepts of military medicine and Naval 
Reserve affairs, and which are available to participating Reserve personnel 
upon request as indicated, are; 

UNITED STATES NAVY MEDICAL NEWS LETTER - Reserve Medical 
Department officer personnel only. 

UNITED STATES ARMED FORCES MEDICAL JOURNAL - Reserve 
Medical Corps personnel and senior and junior Ensign 1915 officers only. 

The Medical Technicians Bulletin, a supplement to the U.S. Armed Forces 
Medical Journal, will be discontinued after the current calendar year. 

All Reserve training activities where Medical Department personnel 
receive training are scheduled to receive these publications routinely. If 
these publications are not being received by the command, attention should be 
invited to this fact. Requests for personal or organization copies should be 
addressed to the Chief, Bureau of Medicine and Surgery, Department of the 
Navy, Washington 25, D. C. 



28 Medical News Letter, Vol. 34, No. 11 



Also available to inactive Naval Reserve Medical Department officers, 
LCDR and above, not on the Inactive Status List is the Naval War College 
Review. Individual requests should be addressed to: Head, Correspondence 
Courses Department, Naval War College, Newport, R.I. 

In making application, Reservists should include their grade, service 
and designator, and include the statement, "Eligible in accordance with cate- 
gory (b) or paragraph 5, BuPers Instruction 1552. 5A. " Also add whether the 
subscription is new or a renewal. Subscriptions are effective for only one 
academic year and those desiring renewal must resubscribe by using the 
printed form that is available in each year's June issue. 

^ rfc rfc A A A 

Terminology of the Naval Reserve 

Terminology commonly used throughout the Naval Reserve: (concluded 
from the last issue of the News Letter) 

INACTIVE STATUS LIST - personnel of the Naval Reserve in an inactive 
status who have been placed thereon in accordance with the regulations 
prescribed by the Secretary of the Navy. 

CATEGORIES OF RESERVISTS - every Reservist is either in the Ready, 
Standby, or Retired category. 

READY RESERVE - those members of the Naval Reserve who are liable for 
active duty either in time of war, in time of national emergency declared 
by the Congress or proclaimed by the President, or when otherwise auth- 
orized by law. 

SELECTED RESERVE - those forces needed immediately at the outbreak of 
hostilities involving the United States. Normally, they would not be ordered 
to active duty for partial mobilization or for limited emergencies unless 
hostilities are involved. 

STANDBY RESERVE - those members of the Naval Reserve who are liable for 
active duty only in time of war or national emergency declared by the Congress, 
or when otherwise authorized by law. 

RETIRED RESERVE - those mennbers of the Naval Reserve whose names are 

placed on Retired Reserve Lists in accordance with regulations established by j 
the Secretary of the Navy. Retired members of the Reserve are liable for | 

active duty only in time of war or national emergency declared by Congress ( 

or when otherwise authorized by law. j 

PARTIAL MOBILIZATION - the limited expansion of the active forces through | 

the selective recall to active duty of individual Reservists and organized 
units. Normally, only Ready Reservists will be recalled in a partial mob- 
ilization. 



Medical News Letter, Vol. 34, No. 11 29 



TOTAL MOBILIZATION - the expansion of the active forces to full wartime 
strength through the general recall of all Naval Reservists. 

ACTIVE STATUS POOL - comprised of all personnel who are in an active 
status except those on active duty and those in a drilling unit in the Naval 
Reserve Program. 

APPROPRIATE DUTY PAY POOL - those personnel issued orders authorizing 
the performance of periods of appropriate duty with pay. 

PROMOTION POINT - a numerical unit awarded for the successful completion 
of a defined portion of an approved training program for the purpose of 
establishing 'eligibility for promotion. 

RETIREMENT POINT - a unit used to credit an individual for participation in 
Naval Reserve training and active duty for use in determining eligibility 
for retirement benefits. 

SATISFACTORY YEAR OF FEDERAL SERVICE - the accumulation of a min- 
imum of 50 retirement points in an anniversary year is considered a "satis- 
factory year. " 

iC? jfe ?&!! jfc !?fe ife 




PREVENTIVE MEDICIIVE 



Control of Acute Respiratory Disease in Industry 

The significance of respiratory diseases as a cause of absence in indus- 
try has been well docunnented by many studies. Acute respiratory diseases 
account for nearly one-half of the absences and at least one-quarter of the 
total lost time. This is estimated as amounting to 150 nnillion work days 
annually in addition to the reduced efficiency which results from employees 
who are on the job in various stages of illness. 

Absenteeisnn is a complex subject. Measures directed solely to the 
control of diseases as such quite probably never will provide the entire ans- 
wer. There is good reason to believe that there is a strong interrelationship 
between a man's health, behavior, and job performance with the kind of man 
he is, where he conaes from, what he wants and needs, what he is facing now 
in his home and personal life, and what he has faced in the past. 

There is little doubt that when science has made available means for 
prevention and control of the common cold, favorable impact on absences will 
be spectacular. 



30 Medical News Letter, Vol. 34, No. 11 



Considerable progress has been made in study of acute respiratory 
diseases during recent years. There is good reason to believe that as more 
money is channeled into research in this field, there will be even more pre- 
cise diagnosis and more knowledge of prevention and control. 

At present, the causative agents of respiratory infections can be iden- 
tified in approximately 50% of all cases occurring in children and adults, 
according to the Scientific Advisory Committee of the Common Cold Fo;ind- 
ation. These identifiable agents include the influenza viruses, the adeno- 
viruses, the J. H. virus, viral agents Z060, and the myxoviruses. 

In infections caused by different viruses, an immune response occurs, 
followed by protection for variable periods of time. Scientists believe that 
properly prepared vaccines similar in antigenic composition to viruses in 
question would have an immunity and protective value. This has been shown 
to be true for influenza and for types 3, 4, and 7 of the adenoviruses. 

There remains a sizable segment of upper respiratory tract infections, 
most if not all of which are caused by viral agents. It is in this segment — 
the most frequent of all — that the common cold falls. At present, there is no 
means of controlling this group. 

Children are the main source of respiratory illnesses among adults. 
In a study made in Cleveland it was found that approximately 75% of acute 
respiratory infections were introduced into the home by children. 

Control of respiratory diseases in industry is limited to three general 
methods of approach. The first avenue of control may be considered under 
the general heading of health education which includes personal hygiene and 
such simple procedures as covering the sneeze, washing the hands before 
eating, and maintaining that intangible something known as general body 
resistance. Adequate control of the environment by proper ventilation, heat- 
ing, and good housekeeping is also important. Finally, specific measures al- 
ready available through vaccines, antibiotics, and sulfa drugs can be considered. 

Some industries have been offering polyvalent influenza vaccine to their 
employees each fall for the past 8 or 10 years. The impracticality of accurate 
prediction of an epidemic and uncertainties of the strain and type of virus likely 
to be responsible have prompted others to discontinue this procedure. Vaccines 
effective against the adenovirus infection also have been developed. Their use 
is not recommended at this time in the adult civilian population because of the 
low attack rate. 

Industrial medicine has a real obligation to take an increasing interest 
both in support of scientific studies and in cooperative ventures to evaluate 
progress nnade. 

During the fall of 195 7, over 400,000 Bell System employees were vac- 
cinated against type A-Asian strain of influenza. The incidence of significant 
reaction to the vaccine was negligible. Analysis of absences in excess of 
7 days due to all respiratory diseases among vaccinated and unvaccinated em- 
ployees during the months of October and November showed a ratio of 1.0 to 4.2 



Medical News Letter, Vol. 34, No. 11 31 



respectively. This represented a group of nearly 9, 000 employees, approx- 
imately two-thirds of whom elected to be vaccinated. 

These preliminary reports are presented only as indication of apparent 
results, and not as finished or scientifically validated research. 

As preventive measures against respiratory disease beconne available, 
industry will be in a position to reach a considerable segment of the adult 
population. The particular industry s decision on whether to do so will be 
governed by many factors which include costs, anticipated results, company 
policy, and potential threat of an epidemic. Perhaps one of the most impor- 
tant considerations will be the possible impact of the disease on productive 
capacity of the industry and significance of this to the welfare of the public 
which it serves. 

The goal still ahead is a challenge to all, and in reaching it there is 
annple opportunity for cooperative efforts between industrial medicine, pri- 
vate medicine, and both voluntary and public health agencies. (Whitney, L. H. , 
The Control of Acute Respiratory Disease in Industry - With Special Reference 
to Influenza: Indust. Med, & Surg. , October 1958) 

9ji ^ :J: ^ ^ $ 

Active and Passive Tetanus Immunization 

Passive immunization against tetanus provides immediate but transient 
protection. In contrast, active immunization with toxoid leads to a slowly 
developing but long-lasting immunity. Passive inamuni zation has numerous 
disadvantages and has never, at its best, given as high a degree of protection 
as does active immunization. Hence, the latter is the procedure of choice for 
the specific prophylaxis of tetanus when time and circumstance permit it to be 

applied. 

Use and Effectiveness of Tetanus Toxoid in Routine Immunization . 
Tetanus toxoid is one of the most effective and innocuous imn:iunizing agents 
known. Because all human beings are subject to soncie chance of contract- 
ing tetanus, all should, ideally, be immunized with toxoid. In particular, 
high-risk groups and groups readily reached en masse should have such im- 
munization as a matter of routine medical and health policy. Adequate 
imnnuni zation against tetanus may be achieved with a variety of separate or 
combined preparations. It is important to administer at least three doses of 
fluid toxoid or two doses of precipitated toxoid in order to establish accept- 
able primary immunization. 

'Basic immunization" may not be regarded as completed until an addition- 
al reinforcing dose is given, preferably 6 to 12 months after primary immuni- 
zation. This reinforcing dose greatly enhances and prolongs the immunity 
established with primary immunization. Immunization of infants is readily 
acconriplished, but, if the infant is born of an immunized mother, an extra 



32 Medical News Letter, Vol. 34, No. 11 



dose of toxoid (or the appropriate combined vaccine) is recommended as part 
of the primary immunization. Such an extra dose is also recommended when 
there is specific indication for early achievement of a high and lasting level 
of immunity. : 

Innmunity to tetanus, once established by adequate basic immunization, 
should be naaintained at a protective level by periodic booster doses. The 
level of immunity falls, though very slowly, for years after basic immuniza- 
tion or re immunization. Hence, it appears wise to. administer booster injec- 
tions at intervals of 4 to 5 years. Shorter intervals are not ordinarily indicated, 
especially since there is some evidence that repeated inoculations may lead to 
sensitization of the delayed type in a snnall proportion of patients. Longer inter- 
vals — up to 10 years or more — do not appear to decrease the capacity of the 
booster dose to elicit a response, but rate of response may perhaps be some- 
what slower. 

A detectable rise in antitoxin level after a booster injection occurs in 
almost all subjects within five days and sometimes earlier. There is some 
evidence, though not unanimous agreement, that fluid toxoid elicits a slightly 
more rapid response than does precipitated toxoid. 

Management of Patients with Tetanus -Prone Injuries . Prevention of 
tetanus after an injury is dependent first upon adequate surgical care of the 
injury, with emphasis upon debridement and exposure of the injured area and 
removal of foreign material. Specific prophylaxis with tetanus toxoid will be 
of incontestable value if the patient has a known reliable history of primary 
immunization within five years or of primary immunization plus reinforcing or 
booster doses at any time. Prompt injection of tetanus toxoid in such patients 
will give adequate protection against tetanus in practically all cases. However, 
simultaneous injection of 1500 units of antitoxin, at a different site, may be 
■-onsidered for patients with clearly tetanus -prone injuries "under conditions of 
exceptional risk, such as a delay of more than 24 hours in treating a miassively 
contaminated or deeply penetrating injury, an interval of over 10 years since 
the last injection of toxoid, or in intermediate situation, a combination of delay 
in treatment and severity of injury. Conabined use of toxoid and antitoxin in 
those few situations in which it is indicated minimizes the risk of fulminating 
tetanus during the interval prior to appearance of booster response to tetanus 
toxoid. This advantage is to be balanced against the hazard or inconvenience 
of a possible reaction to antitoxin. 

Long persistence of protective residual antitoxin titers after a booster 
dose will serve to prevent many cases of tetanus arising from trivial or unrecog- 
nized injuries and will render unnecessary repetition of successive emergency 
booster injections of toxoid at close intervals except when risk of massive 
tetanus infection is apparent. 

In patients without a valid history of adequate tetanus toxoid immunization, 
tetanus antitoxin must be ennployed for emergency prophylaxis of tetanus -prone 
injuries. The customary dose of 1,500 units does not give entirely reliable 



Medical News Letter, Vol. 34, No. 11 33 



protection, and a dose of 3,000 to 5,000 units is recommended when prophy- 
laxis of tetanus is medically indicated. This dose should be increased if 
complete debridement is impractical or if significant delay has occurred in 
treating the injury. 

The unimmunized subject should be immunized as soon as practical. 
It is possible to begin active immunization at the same time as prophylactic 
antitoxin is given, but the procedure is effective only if the dose of antitoxin 
is relatively small and if an extra dose of toxoid is included in the primary 
immunization schedule. Precipitated toxoid is preferable to fluid toxoid for 
this purpose. (Edsall, G. , Specific Prophylaxis of Tetanus: J. A.M. A., 171 : 
417-427, September 26, 1959) 

:>: :^ ^ 3}c ^ :); 

Hospital Sanitation 

In the period immediately preceding "World War II, hospitals were prob- 
ably the cleanest they have ever been in history. Cross-infections were held 
to a minimum. Sterile and aseptic techniques were highly developed. Discov- 
ery of sulfonamides and their action on bacteria in 1936 initiated a period of 
laxity in hospital sanitation which was aggravated by the discovery of anti- 
biotics in 1943. World War II also left hospitals with a personnel shortage 
and a consequent deterioration in cleanliness. It became fashionable in the 
immediate post-war period to prevent cross -infections by prophylactic shots 
of antibiotics instead of maintaining a high standard of cleanliness. This 
practice undoubtedly reduced the payroll, but the price of poor sanitation had 
to be paid sooner or later. 

Concurrently with this development was a laxity in pest control which 
was occasioned by the discovery of DDT during World War 11. About 1951, 
reports began to appear in scientific journals concerning resistance of certain 
insects to DDT. Shortly afterwards certain bacteria were identified as resis- 
tant to penicillin. Among these resistant bacteria was the Staphylococcus 
aureus soon glamorized as the "golden villain" in a national consumer maga- 
zine. The real villain was not the staphylococcus — poor sanitation was. 

Early in 1957, the Program in Hospital Administration, Northwestern 
University, summarized a few reports of hospital-acquired infections which 
included not only staphylococcal, but also streptococcal, salmonellal, and 
coliform infections, and gas gangrene, tuberculosis, viral hepatitis, and other 
microbial diseases. To these could be added certain fungal diseases which did 
not receive much publicity at the time. The return to a state of biologic clean- 
liness in the hospital was advocated. After a lapse of nearly 20 years, it will 
be difficult to pick up old aseptic techniques at the point they were abandoned. 
However, this must be done to solve this problem, even if it means the return 
to smelly antiseptics. 



34 Medical News Letter, Vol. 34, No. 11 



The summary report contained a proposal to appoint a Committee on 
Infection Control to study the situation in the hospital and to make recona- 
mendations for correction of existing defects. This committee was later 
endorsed by the American Hospital Association and the Joint Commission on 
Accreditation of Hospitals. 

After determining that there is a situation in need of correction, the 
cominittee must inspect the hospital from top to bottom and report honestly 
and fearlessly the true facts of the situation. Some authorities recommend 
that an elaborate system of reporting cross -infections be maintained by the 
medical staff of the hospital while others prefer to place this responsibility 
in the hands of the nursing staff. In theory, then, the reports are passed to 
the committee to investigate the causes. After the committee completes the 
investigation and identifies causes, it makes recommendation to the adminis- 
tration. 

The first source of cross-infection is the patient himself. It is now a 
standard committee recommendation that every patient suffering from an 
infection, such as a boil, abscess, infected wound, sore throat, or dysen- 
teric condition be isolated and handled according to the techniques usually 
employed for infectious diseases. This calls for elaborate hand washing, 
gowning, masking, and in some instances, the use of rubber gloves before 
approaching the patient. Some hospital administrators fear that these drastic 
measures will increase the payroll of the hospital which is currently at an all 
time high. Some physicians and nurses — out of practice in such techniques 
for so many years — regard these measures as extreme. There is resistance 
to overcome in instituting strict isolation of all infected patients. 

The environment of the infectious patient also must be subjected to 
drastic sanitation procedures. The patient's room should be cleaned as if 
he had smallpox or tuberculosis before placing another patient in that room. 
The room itself should be completely and thoroughly washed down with effec- 
tive chemical substances having a residual bactericidal action. Floors, 
walls, furniture, cupboards, and bathrooms should be thoroughly disinfected. 
Drapes, mattresses, pillows, screens, and all textile materials should like- 
wise be treated and disinfected. 

The adverse publicity given to hospitals as a result of articles in 
national journals has undermined public confidence in hospital cleanliness to 
such an extent that it will be difficult to restore the faith of people in the 
sterile atmosphere of the hospital. Taking a leaf from the book of some well 
operated hotels and motels, hospitals must now present the patient with his 
own sanitized drinking glass wrapped in its own sealed container, his own seal- 
wrapped sterilized bedpan, urinal, and water carafe with the final psychological 
touch of the paper tape across the toilet seat. The use of disposable nnaterials, 
such as urinals, paper towels, sputum cups, and other disposable containers 
will further tend to create a favorable impression upon the patient. 

In most hospitals, a complete indoctrination and training of personnel 
handling patients will have to be undertaken. Personnel handling patients with 



Medical News Letter, Vol. 34, No. II 35 



infections due to staphylococci will soon become carriers of the infection 
unless adequate precautions are taken. Frequent examination of personnel 
handling infectious patients, throat cultures, and strict sanitary discipline 
must be put into effect. All personnel working in sensitive areas in the 
hospital, such as surgery, maternity sections, and nursery, should be 
obligated to change clothes completely and take a shower bath upon entering 
the hospital and again upon leaving. Locker rooms of doctors, nurses, and 
enriployees should be thoroughly swabbed down at least once a week with 
residual bactericides and frequent cultures should be made of these areas. 
All personnel suffering from any kind of infectious disease should be obliged 
to report to the employee health service under penalty of dismissal whenever 
afflicted with pimples, boils, sore throats, or diarrhea. If they are found to 
be suffering from such infections, they should be transferred to a less cri- 
tical part of the hospital or sent home without loss of pay . 

Engineering aspects of the hospital present a problem which is often 
insurmountable in old hospitals. Old buildings in a poor state of repair can 
be kept clean only with the utmost difficulty and expense. Circulation of air 
must be checked and frequent cultures nnade for presence of bacteria in 
humidifiers of the airconditioning system, as well as ducts, vents, and 
screens leading to sensitive areas, such as the operating room, delivery 
room, and infant nursery. 

All laundry and refuse chutes should be nailed shut. Garbage disposal 
may be accomplished by means of sealed plastic bags. These should then be 
transported on special carts and should be incinerated. Fomites need espec- 
ially careful treatment. Linens should be handled by means of carts. Tech- 
niques of bringing dirty linen to the laundry and clean linen back from the 
laundry should be well established. Under no circumstances should the same 
employee receive dirty linen and issue clean linen nor should the same car- 
riers or containers be used for both clean and dirty linen. 

Elevator, dumbwaiter, and conveyor wells should be cleaned daily to 
prevent an accumulation of garbage and infected dust which ultimately circu- 
lates through the hospital with each change in air pressure and air current. 
Infection control nnust be considered in the maintenance of equipment, such 
as incubators, autoclaves, and oxygen therapy, anesthesia and laboratory 
apparatus. For example, techniques of cleaning refrigerator compressors 
should be worked out between the maintenance department and the committee. 
The housekeeping department is also responsible for environmental sanitation. 
Janitors' closets, mops, waste baskets, and cleaning processes should be 
closely supervised for good sanitation. 

The most sensitive areas are the surgical operating room, the delivery 
room, and the infant nursery. The committee must review all techniques in 
these areas and establish rules and regulations that must be observed. In the 
operating room, for exanaple, an automatic, large -dial clock should be in- 
stalled over the scrub sinks so that all can check the length of time that each 



36 Medical News Letter, Vol. 34, No. 11 



person scrubs. Such clocks were standard equipment 30 years ago in many 
hospitals. They were usually set for a 10 -minute period. 

The use of disposable drapes in the delivery room is another procedure 
that should be considered by the Comnaittee. Policies should be formulated 
and standing orders written. In the infant nursery the methods of cleaning 
screens, heating coils, tables, doors, and baby scales should be regulated. 
Sanitation in the fornnula room should also be regulated. The techniques used 
by the central sterile service in preparing sterile packs should be considered 
thoroughly. The use of disposable or reuseable syringes may depend upon 
safety rather than cost. 

In addition to the work in sensitive areas of the hospital, the committee 
should inspect thoroughly every nurse's station, examining desk drawers, 
cabinets, and cupboards for clutter and untidiness which may breed disease. 
The same principle applies to ordinary office sanitation. All desk drawers, 
filing cabinets, stockroonas, and cupboards should be cleaned and thoroughly 
sanitized with bacteriostatic connpounds at least twice a year. Dust from 
offices is just as infectious as that from other parts of the hospital. 

Laboratory and x-ray departments should not escape the scrutiny of 
the committee. All cupboards and cabinets should be opened for inspection. 
A strict rule should be enforced against eating snacks, sandwiches, and other 
vermin attractors in the department. Even though the department may be ex- 
tremely busy, consumption of food while a technician is working is not war- 
ranted. 

The physical therapy department is a fertile source of contamination if 
adequate sanitation is not enforced. Water baths and hot packs can develop 
slime quickly if not disinfected. Exercise equipment must be disinfected 
regularly. In the emergency room, stretchers, wheelchairs, furniture, and 
the entire general area should be swabbed down frequently with disinfectants. 

Kitchen sanitation is of the utmost importance. Regular examinations 
of food handlers is required by law in many places. Cooking and food prepar- 
ation equipnaent, such as slicers, mixers, and peelers, must be sanitized 
according to standard techniques. Rarely used closets, cupboards, and nooks 
may harbor almost anything from pieces of half consumed dry toast to umbrel- 
las and galoshes stored for inclement weather. These spaces should be cleaned 
out regularly. 

The foregoing recomnnendations are samples of the problems which con- 
front every Committee on Infection Control. In the present state of hospital 
sanitation, membership on such a committee should be a full time job if the 
connmittee is to be effective. 

Experience indicates that the committee is usually ineffective in making 
changes in the cleanliness of the hospital because its mennbers have neither 
the time nor the knowledge to do a thorough job. In order to do its job ade- 
quately, the committee must be provided with a full time qualified sanitarian to 
act on its behalf as a staff member. As presently constituted, the committee 



Medical News Letter, Vol. 34, No. 11 37 



is strictly a "do-it-yourself" operation to be undertaken during the spare time 
of each member. An entirely new professional person to be called a Hospital 
Sanitarian should be assigned as a full time member of the health team with 
primary responsibility for sanitation of the hospital. This person could cut 
across departnaent lines and have authority to scrutinize, report upon, and in 
some instances, enforce the regulations of the hospital for control of infections. 

Experience has shown that violations of techniques occur not at the lower 
levels of personnel, but rather among the most highly placed responsible per- 
sons. Department heads, administrators, directors of nurses, and practicing 
physicians are sometimes the worst offenders in breaching regulations. 

In the beginning it may be necessary for the hospital sanitarian to be res- 
ponsible only to the committee. While each member of the committee is know- 
ledgeable in his or her own specialty, all are remarkably ignorant of what goes 
on in other departments. The sanitarian will be expected to fill these gaps and 
to examine every department from the sanitation viewpoint. For example, the 
housekeeping department rarely penetrates into the autopsy room while the 
director of nurses knows next to nothing about sanitation in the kitchen. 
(Letourneu, C. U. , Hospital Sanitation; J, Milk and Food Technology, 22: 195- 
198, July 1959) 



Driving Hazards Tripled After Sundown 

Until mid-March hours of darkness will be greater than hours of light. 
Although only one-third as many highway nniles are logged after the sun goes 
down, there are three times as many fatalities per 100,000,000 miles driven 
then as in daylight. Because of peculiar dangers of nighttime driving, special 
precautions are necessary — especially in the critical hours of dusk. 

In starlight, field of vision is one-tenth what it is in sunshine, and a 
person with normal vision by day may not see comparably well at night. Fore- 
shortened vision is a major cause of nighttime accidents. Also, the driver's 
job is complicated by glare from oncoming traffic, inadequate illiimination of 
roads, obsolete vehicle lights, poor road signs, and unlighted vehicles parked 
on narrow roads. In addition, there is fatigue and highway hypnosis, suddenly 
encountered ice slicks and fog pockets, erratic speed of drivers, and drunken 
drivers. 

Three basic abilities help offset such risks: to see well under low illum- 
ination, to see against glare, and to recover rapidly from glare effects. Every 
driver should know to what degree he has these characteristics. A vital con- 
sideration is age. At age 20, 23% of all persons have substandard sight; at 
age 60 this rate is 82%, increasing sharply after age 40. 

Modern headlights illuminate the roadway for 300 feet. At 60 mph on 
a dry road, it takes at least 300 feet to stop a car. Therefore, it is easy for 



38 Medical Newd Letter, Vol. 34, No. 11 



a motorist to over -run his headlights and become involved in an accident. 
The higher the speed the shorter the range of vision. While headlights may- 
pick out bright objects for 400 feet or more ahead, they may not illuminate 
dark things within 200 feet. Some vehicles exhibit reflective material which 
can be seen one-half mile in headlight beams, yet give the speeder only 30 
seconds or less to stop. To cut down nighttime accidents, such materials 
are used increasingly on license plates and at strategic points along highways. 

Experiences of several cities suggest that cost of adequate highway light- 
ing may be offset in reduced deaths and property damage. More than Z 1,000 
persons were killed in nighttime accidents in 1958. Good roadway lighting 
might prevent 10,000 such deaths each year. Fixed lighting systems are a 
necessity on modern high-speed highways— particularly at "driver-decision 
areas. " 

Some states now require night driving in road tests, and evaluation of 
peripheral vision and depth perception is proposed. The National Conference 
on Driver Education urges practice after dark in high school driver training 
courses. In 16 states improved safety records have resulted from lower 
nighttime speed limits. 

Dual headlights on late model cars are another effort to reduce night- 
time accidents. However, visibility is still reduced by oncoming lights. 
The courteous safe driver will dim lights and slow down at night. Further- 
more, low beams are better for driving in fog, rain, snow, and dust. 

Few people realize that headlights require periodic adjustment. A frac- 
tion of an inch of misalignment can divert the beam several feet on the road. 
An estimated 50% of all cars need lights aligned, resulting in 80% loss of 
illumination. Dirty lenses can cause up to 25% loss of illumination. 

With days growing shorter and nights longer plus other difficulties, it 
is worthwhile for any driver to be more alert. Safe driving is still the res - 
ponsibility of the person behind the wheel . (Angell, O. , Driving Hazards 
Triple after the Sun Goes Down: Driver Education Newsletter, 3: 3-4, Fall 
1959) 



Preventive Medicine Laboratory Methods 

"Preventive Medicine Laboratory Methods" is no longer available. This 
publication will not be reprinted, nor will it be republished as Chapter 12, 
Manual of Naval Preventive Medicine, as previously proposed. 

Current editions of "Standard Methods for the Examination of Water, 
Sewage, and Industrial Wastes" and "Standard Methods for the Examination 
of Dairy Products, " published by the American Public Health Association, 
Inc. , 1790 Broadway, New York 19, N. Y. , are recommended for use as 
laboratory standards. (Sanitation Section, Health Practices, PrevMedDiv) 



Medical News Letter, Vol. 34, No. 11 



39 



SPECIAL NOTICE 

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if continuation on the distribution list is desired. Only one answer required. 

(Continued on page 40) 

(first fold) 



U. S. Navy Medical School 
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Medical News Letter, Vol. 34, No, 11 



EXCEPTIONS (reply not required) 

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DUTY, receiving News Letter at military address 

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Therefore, all others — active duty Medical and Dental Corps officers 
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